86-113 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San'Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City_515TOOT014 Lot Size PM 1 Owner's Name On IV)M _W R�. Address Phone 931- IA21 Contractori4rZt2LT� S Sys Address?_ �D� moi' k A License No.,„�� Phone 4 -9ra0 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ V PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE-TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE f_ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Weli Excavation Dia. of Well Casing r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications }O Public ❑ Other ❑ Delta Depth of Grout Seal. Type of Grout ❑ lrrigation�, —_______�gpprox.,Depth i❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. r State Work Done_ Well Destruct!n ❑ Well Diameter Sealing Material (top 501 _ Depth Filler Material iBelow 50'), TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION N DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence� Commercial— Other r .a` ` 'Number of living units: A— Number of bedrooms Character of soil to a depth-of.-3 feet:- r .- - •. -- Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No.;Compartments# PKG. TREATMENT PLT. ❑ .... _ " �.; � Method of pisposal�. Distance to nearest: Well foundation Property Line 1 ' LEACHING LINE j D No. & Length of lines 11 _ Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line + SEEPAGE PITS ■ Depth Size q _ Number __ SUMPS ❑ Distance to nearest: Well ti .^ Foundation 12 Property tlne DISPOSAL PONDS- v ❑ I hereby certify that I have prepared this apblication and that the work will be done in accordance with Sari�loag6iri,c7ounty ordinances, state laws, and rules and regulations of the San Joaquin Local Health-District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work"for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X 9 Title: Date: FORDEP R E T USE+ONLY,, w 1 Application Accepted by r Date Ar !/ Pit or Grout Inspection by Date Final Inspection,by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 N. FEE AMOUNT 6L)E`��+ AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO:,`, � INFO CASH :i, N + EH 13-24(REV.1 x 5) �Q EH 14.28 �b a r .